NOTE: As per the instructions, submit only one provider ID number on the claims attachment cover sheet. Submission of more than one provider ID number may result in the attachment cover sheet and related attachment not being accepted.

Claims Appeal Request Form

Claims Appeal Request Form (PDF)

Instructions (PDF)

This form is to be used when a provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.

UFEF/Prescription Drug PA Request Form

UFEF/Prescription Drug PA Request Form(PDF)

The form is intended primarily for use by prescribers, or those designated and authorized to act on behalf of prescribers, to:

Request an exception to a prescription drug formulary.

Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form

Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form (PDF)